Posted
by
samzenpus
on Monday October 14, 2013 @02:55PM
from the better-luck-next-time dept.

Nerval's Lobster writes "In theory, the federal government's Health Insurance Marketplace was supposed to make things easy for anyone in the market for health insurance. But fourteen days after the Website made its debut, the online initiative—an integral part of the Obama administration's Affordable Care Act—has metastasized into a disaster. Despite costing $400 million (so far) and employing an army of experienced IT contractors (such as Booz Allen Hamilton and CGI Group), the Website is prone to glitches and frequent crashes, frustrating many of those seeking to sign up for a health-insurance policy. Unless you're the head of a major federal agency or a huge company launching an online initiative targeted at millions of users, it's unlikely you'll be the one responsible for a project (and problems) on the scale of the Health Insurance Marketplace. Nonetheless, the debacle offers some handy lessons in project management for Websites and portals of any size: know your IT specifications (federal contractors reportedly didn't receive theirs until a few months ago), choose management capable of recognizing the problems that arise (management of Healthcare.gov was entrusted to the Medicare and Medicaid agency, which didn't have the technical chops), roll out small if possible, and test, test, test. The Health Insurance Marketplace fiasco speaks to an unfortunate truth about Web development: even when an entity (whether public or private, corporation or federal government) has keen minds and millions of dollars at its disposal, forgetting or mishandling the basics of successful Web construction can lead to embarrassing problems."

That sounds familiar.. I've said the same thing here and elsewhere. But it's not like my analysis is unique. There are lots of people who have done large implementations in the past. This one turned out with the expected results. They'll get it working right in a few months.

not really, there are those that act as engineers which design the frameworks, methods and utility of a piece of software, and then there are those that actually build it. It would be more fitting to call them software architects rather than engineers though.

Remember that this is only for people that live in states that tried to stall off the inevitable. I live in Kentucky and despite being a pretty red state we have a Democratic governor and he saw the writing on the wall. Rather than try and delay and delay it we have our own. Numerous other states did the same thing. I haven't heard anything about ours being down.

Your Democrat governor (and several others) did not see the writing on the wall. He was simply not opposed to the system itself the way some other governors were, and worked to build it at a state level. Other states have governors who fought the program and the result is those living in those states have to deal with the broken federal one.

The "writing on the wall" idea is nonsense. The reactions of governors have been political, not practical, as far as whether to set up state systems. One needs only

The political rhetoric is irrelevant. The point is that states implemented their own systems and none of them have been declared a disaster. You don't hear about any of them because they are working as intended. All of these other systems are just too boring to make the news.

Each of them stands as an example of why the problem is not an insurmountable one and perhaps not even a terribly difficult one.

The point is that states implemented their own systems and none of them have been declared a disaster. You don't hear about any of them because they are working as intended.

Sadly, this is simply not true.

Oregon had been running ads for CoverOregon [coveroregon.com] for months prior to Oct. 1. Cute ads, catchy music, but no indication of exactly what "Cover Oregon" was. Unicorns and pixie dust.

Come Oct. 1, the website went live. Unfortunately, they hadn't yet implemented the details of how to sign up, ignoring the basics of "how much will you have to pay" based on income, etc. That part of the website is, to this day "Coming Soon".

You can sign up, but you have to contact a "Community Partner" (new name for "Insurance Agent") on your own. They'll point you at one, but interestingly, the law doesn't require that "partner" to tell you about anything other than the plans his company sells. Lowest rate? Well, look here at my glossy brochure,...

And no, this isn't how it was intended to be. It just wasn't finished, and still isn't. It did make the news, but only in Oregon media. Who cares about failures of the health care exchanges in someone else's state?
BTW, Gov. Kitzhaber is a Democrat and a physician who is fully behind taxpayer-funded health care for all.

It's because of Appalachia (one of the poorest regions the nation). Entitlements have historically been very important to the area, as well as the rest of the state outside of its two urban areas. While being part of the Bible belt has heavily influenced the conservative side (percentages for Bush Jr. and Romney were among the highest in the country).

You have to remember that, prior to Nixon's Southern Strategy, southern Democrats (AKA Dixiecrats) were the Tea Party of their day: racist, xenophobic, religious fundamentalists bent on socially regressive and theocratic policies.

The south remained solidly Democratic from 1865 to 1965, a legacy of the Civil War and Reconstruction. The only thing that got them to switch sides was because the butthurt of a Yankee Catholic giving civil rights to the n*****s was greater than the butthurt of a Republican giving them freedom in the first place.

Most people tend to forget that, from Lincoln to Teddy Roosevelt, the Republicans were the progressive party, and the Democrats were the Conservatives. It wasn't until after the Taft-Roosevelt split at the 1912 Republican National Convention in that the GOP started becoming the party of big business and fiscal conservatism. The progressives eventually migrated to the Democratic party, but this just exacerbated the existing split between the northern Democrats and the Dixiecrat faction. For much of it's history the Democratic party was as dysfunctional and fractious as the GOP is today - unsurprising, considering that the Tea Party, the Dixiecrats, and the Civil War era Know Nothings are basically different manifestations of the same ideology and encompass the same demographic.

the Tea Party of their day: racist, xenophobic, religious fundamentalists

You should actually attend one of the Tea Party rallies sometime instead of parroting media nonsense.

The Tea Party rallies I have seen all have a far greater minority participation than any Occupy rally ever. They also love immigrants - legal ones - which again, attend Tea Party rallies because they don't think it's fair that illegal immigrants get to skip the paperwork and jump lines to get in.

Good post, I would make just one important distinction. The teens were when the progressive side of the Republican party died and the fiscal conservative strain we are so familiar with today became dominant (famously embodied in the Coolidge administration), but the pro-business strain of the GOP existed from the very beginning of the party. In fact that was the major source of strain between Roosevelt's progressivism and the rest of the party, since Roosevelt was so staunchly anti-trust.

For states that set up their own exchanges, there are generally offices available as well as phone lines people can call. Many of the states that opted out are also trying their damnedest to block any perceived successes for the ACA, and have taken steps to hinder their establishment. How much help someone can expect in signing up depends entirely on what state you're talking about.

How many homeless file a tax return to begin with? I bet most of them don't have a drivers license or know their SSN number. You have to some kind of mailing address or permanent residence for these things. The people I think it would hit hardest by being online are the elderly and working poor. But they can always call the toll free number and talk to a person.

"Unless you're the head of a major federal agency or a huge company launching an online initiative targeted at millions of users, it's unlikely you'll be the one responsible for a project (and problems) on the scale of the Health Insurance Marketplace."

Going by budget, even if you are the head of Facebook and Twitter, you are still not going to be responsible for a project on the scale of the Health Insurance Marketplace.

Facebook and Twitter started out small and grew. That's also true of Google, Amazon, and just about any other very high volume site. This is different because they had to build a site and then, on the first day, turn on the fire hydrant all the way. I'm sure there are plenty of things they did wrong, and it was probably very badly organized. Nevertheless I'm curious what the best way to handle something like this would be. How many people have worked on a project where they had to go from zero to millions o

I don't see how anybody could build a semi-complicated system from scratch in a few months. A system this big would take at least a year to get right, and that's if everything was spec'd appropriately, and the coders were good, and the project was managed well. Since the project actually got under way only several months ago, I knew it would be - at the very least - quirky. If it ran at all.

It's essentially an e-commerce site with a government subsidy element added to it. There are any number of similar sites that already existed. They were created to fill the same basic market need by people interested in making a buck.

Since this whole thing was a gift to the insurance industry, perhaps the feds should have considered that the industry may have made a useful partner. Let all of the insurance sales men out there be honorary do-gooders helping themselves while helping Obama's agenda.

From what I heard you pretty much just register on the site, other than needing to support a rather large number of concurrent users, there are already suits of programs that do everything that this projects needs.

You could set up a Drupal forum in a week with the required content, and then just buy some ultra plan on Amazon cloud servers.

In my experience of building e-commerce sites (over roughly five years) the actual *building* of the site isn't the difficult part. I've taken a barebones install of Magento (or Prestashop, etc) and themed the front-end, by myself, in just two/three weeks. Looking at this site, I can't imagine the front-end would take any longer.

The proverbial iceberg, though, is what you're looking at. The bits that take the most time are all the logistics bits like shipping, payment processing, which customers can purchase what, how are discounts handled, tiered pricing, product entry, admin training, etc. I would guess that 90% of my conversations with clients over the years involve some logistics bit, not whether the buttons on the checkout page are the correct color of blue.

And then to top all that off, you have the infrastructure to worry about. You aren't necessarily dealing with a web server and that's it. You might have a cluster of web servers that need to talk to a cluster of SOLR servers. You might have to implement solutions for payment processing servers.

In the end, these items all take a great amount of time not because of how complex they are to implement, but instead it has everything to do with the *people* that are organizing this information. Hell, can you just imagine the nightmare it must have been to get all the insurance companies to provide all their data/plans in a standardized format so they could be integrated to the store front?

In the end, though not unexpectedly, they ran out of time and testing was shat upon. Every relatively complex site I have ever built or worked on has had testing shat upon. Now that I have just a single site that I develop and work on, testing happens all the time since I am my own boss as far as deciding what I need to work on. For every other project out there where the developers aren't the ones that even have a say in what areas are focused on, testing will always be a second-class citizen.

Most states have this worked out pretty well for car insurance. There's a great market, you buy it just like anything else with no exchanges needed, it's just another service. If you're especially high risk, the insurers are required to take you as a customer at government-limited rates, but in return everyone is required to buy insurance. Seems to work well for all involved, and for 90% of customers the government is just not involved in the purchase process (nor is your employer, nor any other third party).

The regulations surrounding insurance products are dealt with by the relevant insurance providers just like any other industry. Amazon doesn't have to bother with insurance regulations any more than they have to deal with the FCC regulations on your phone or computer.

The problem of privacy is not even interesting. It's purely a matter of policy and whether or not you are willing to enforce a certain set of rules.

Part of the problem is the usual problems with large-scale IT projects: it's not until you're well into it that you really get a grasp of what's involved. Nothing government-specific there, that plagues all large IT projects in private industry. Part of the problem, though, lies exactly in the fact that contractors were used. Contractors are mercenaries. They're here to deliver this project, and once they get their paycheck they're on to other work. They won't be around to deal with the fall-out and maintenance headaches from their work, and they don't have any vested interest in the quality of their work as long as it's good enough to pass review and get their payment check cut. In fact, poor quality is actually an opportunity to get paid twice since fixing the problems is a new project. Full-time permanent employees may not be as efficient as contractors, but on the other hand they've got a vested interest in making sure the system doesn't create any more problems than necessary because they know they're the ones who're going to have to clean up the messes. Long-term employees also have a better grasp of what's already involved in the current system, which translates directly into a better grasp of what the new system will need to do. They're less likely to miss major complications because they already have to deal with them.

Part of the problem with contractors is also the fact that large organizations like governments limit themselves to Tier 1 contractors. And there aren't a lot of those. So it rapidly becomes a situation where the Tier 1 contractors aren't really concerned about quality and results, because they know their customers will by policy refuse to consider any alternatives outside a small set and those others aren't any better about quality. If the government switches from contractor A to B, that means B can't take on another customer who takes their business to A (because A and B are the only Tier 1 firms and the customer can't consider anyone who isn't a Tier 1 firm) and it's a net wash for A.

Contractors are mercenaries. They're here to deliver this project, and once they get their paycheck they're on to other work. They won't be around to deal with the fall-out and maintenance headaches from their work, and they don't have any vested interest in the quality of their work as long as it's good enough to pass review and get their payment check cut. In fact, poor quality is actually an opportunity to get paid twice since fixing the problems is a new project. Full-time permanent employees may not be

I'd also note that there's upsides to having people interested in doing the minimum. As my father put it about the ore-processing mill he was general foreman of, "I don't want the industrious, energetic twit who'll muck out the basement on Monday because the tanks overflowed, and muck out the basement on Tuesday because the tanks overflowed, and muck out the basement on Wednesday because the tanks overflowed... I want the lazy bum who'll figure out why the tanks keep overflowing and fix it so they don't so

Now I'm not saying incompetence isn't plausible, or even likely. But I also wonder if this wouldn't be somewhat intentional on the part of a few people as a political maneuver, whether via who the contracts went too, artificial delays, etc etc, in order to make the project become politically embarrassing. Sabotaging a co-workers project is not unheard of in the corporate world to get ahead or inhibit their credibility, so why would the government be any different...

As a software engineer, I'm very curious about where this $400 million went. In all the articles about this project, I've never seen a breakdown of where the money was spent, at least at the granularity of people/hardware/software. Typically software projects spent most of their budgets on people, but a $400 M project that is basically a year old implies on the order of thousands of employees. That can't be right? Did they get dinged by ridiculous licensing fees from the usual suspects? Where did the money go?

Seeing that the current administration is, by their own admission, the most transparent administration in history, it shouldn't be difficult. Moreover an entire legion of crusading journalists are just waiting for leads to fall into their laps so they can take down high-ranking Democratic government officials for corruption. There are multiple Pulitzer Prizes waiting for those who do these deeds. So, don't worry!

It's a website that needs to be able to handle 3million visitors per day, with the majority of them being signups, or at least hitting the calculator. That's a lot of deep hits that can't be cached.

Then, add on a back-end that has to talk to insurance companies. These guys still have a tonne of Cobol code running around. There's nothing wrong with that (Seinfeld!), but I think it might indicate that their systems aren't necessarily built for online, real-time querying.

To recap, it is a multi-tier system:

1) Front end, performing user signup, and calculator.2) Back end database. HIPA compliant, Sarbanes-Oxley compliant and able to deal with 100m customer records.3) Feeds to remote systems, also HIPA compliant, Sarbanes-Oxley and other stuff.

So, you've got something that looks a lot like twitter (the back-end links), only more expensive because it needs to be Capital S secure, along with something that looks like an insurance company (the middle tier) and finally something that looks like a dot-com (front end calculator).

That's already a lot of hardware and software. "Free" open source doesn't actually save a lot of money here, since most of the money is in support (over 1/2 the 5year cost!). Now, triple it do deal with hot site failover, backups and other various disaster recovery plans.

Although they've had 3 years to get the system complete, the software was probably only developed in the last 10-12 months (at most). The rest of the time would have been spent in getting agreement on the data exchange formats with the insurance companies, deciding on a vendor to use for each part, and standing up an internal team to manage it. Then add in several parties involved playing schedule chicken with Congress, hoping for the whole thing to either be delayed or scrapped. Fun!

Finally, they went for a nationwide rollout for political reasons, which was guaranteed to result in peak traffic on day 0.

So, something similar to what I've implemented twice in the past at different companies for $10 million in software development and $10 million in hardware? (monthly operational costs for bandwidth can get expensive, but that's not included here).

So what does the other $600 million+ goes towards? Bribes and other assorted waste?

Most people don't realize how bad news stories are until they see one they have personal knowledge of. Guess, what, the others are generally just as bad.

I've been in the unfortunate situation of working for a government agency when Booze Allen Hamilton came in to help make changes and improve things. They did much of the former and none of the latter.

Typically, dealing with whoever was going to actually use the process they were changing was something the Boozers did just to check off an item on a list. They did not listen to users because they assumed government employees were all idiots and could tell them nothing they really needed to know about the processes they were about to change.

Personally, if I were going to change business processes that had been in place for decades I'd want to talk to the people who work the current processes and find out how they work before I started trying to think up better ways of doing things. BAH never did that. They brought in workers for planning sessions, listened for a couple of days, then distilled the results of those discussions into a document of findings that was obviously written before the research ever started and contained exactly zero input from the field workers who truly understood job requirements.

Boozers, in my organization, were almost universally so convinced that their shit didn't stink that they were worse than useless. In the course of years of contacts with them, I met exactly ONE who listened, learned, and improved things.

Based on those past experiences, I can only surmise that the folks responsible for this current fiasco simply said "Oh, we don't need to talk to anyone from the government about how they run web sites that stand up to incredible traffic swings. We know what we're doing."

It seems like many times when a large government entity spends billions of dollars on a large IT project to consolidate or make more efficient the handling of lots of data, it frequently ends up in massive amounts of wasted money and failed projects, with lots of pork doled out to consultancies and middlemen, and in the worse cases ends up with the project abandoned entirely with all the money down the toilet. Many examples have been posted to/. in the last 10 years.

I don't know about you, but does the site really need links and JS from ad sites (like doubleclick, chartbeat), YouTube, and Facebook, as well as whatever googletagmanager and optimizely provide - as noticed by what I had to temporarily allow in NoScript - to simply make the site work to, you know, helps people get access to healthcare insurance?

I find it interesting that the team behind the technical aspects of Obama's presidential campaign were so capable (more here [theatlantic.com]...it's a great read) and yet he still chose the tried and false alternate model of outsourced government contractors to handle this.

A methodology more similar to what was used on his campaign would have been far more successful and cost significantly less.

The whole point is that they weren't contractors, or at least that they were individual contractors rather than a single contract firm. Romney went the contract firm route and his tech operations went down for the count 30 minutes into election day. That and the guy in charge of Obama's tech was ex-Twitter and made decisions that scaled really well.

In 2008, there were techies who volunteered to work on the Obama campaign who were told to go knock on doors. The 2012 campaign realized that that was a tragic m

>> when an entity (whether public or private, corporation or federal government) has keen minds and millions of dollars at its disposal

Not sure there's any evidence of "keen minds" here, but I'd suspect that the root of the problem is that there were millions of dollars allocated to the project. With that kind of money, the incentive is probably to put as many billable bodies on the thing, regardless of qualifications or result.

This happens every time a major new internet service is launched. And it _always_ will. See, here's the problem: at launch everyone is interested and wants in. After a few weeks/months the interest dies off and the site hits a BAU point. So if you're designing one of these sites you're stuck either:

a. Spending billions on infrastructure for 3 months tops of high volume and then getting ripped to shreds in the press for 'wasting' all that money. or...

b. Taking your lumps up front and waiting a few months for people to forget about it.

The guys running healthcare.gov opted for 'b.', and I would too. The kinds of people that just want to say bad things about the ACA would have a field day with 'a.', with 'b.' they'll have to acknowledge (or at least ignore) the fact that in a few months it'll be working more or less as intended.

It's funny all the finger pointing, how the government screws up IT, etc.
I've seen dozens of major web site projects and many other major IT projects totally screwed up. It's not government, it the human people involved and they are everywhere!

What you call "Central Planning" is also known as top-down design. It's a valid design method, it certainly works and is used regularly. Done properly, it produces cleaner designs than bottom-up alternative. You seem to argue for the bottom-up design to be the single correct method because it fits your right-wing ideology.

You're darn right I won't be put in charge of such - not without a gun to my head. I'd want to de-scale anything down to a size where you could reasonably spec and test it. As the article says, "test, test, test". A formative experience in my programming was FORTH, a language that strongly rewards small incremental experiments, compiling as you go, building from small functions up to large ones. I'm not saying use FORTH, but the philosophy of getting the basics working and building up has really worked for me for a whole career.

By contrast, all the large-scale projects I've worked on have all taken a philosophy like building a skyscraper or 747 - no one person can comprehend it, design everything before the first screwdriver is picked up, so the design process goes on for months and years, etc. And then you have "crunch time" from then on as the fond beliefs of the design team smack into reality, and the specs are proven to not match needs. Incremental building and testing tends to reveal these problems.

The fear that drives these philosophies is that you'll have the thing mostly built...and discover it doesn't meet every need and can't without some huge rebuild, because you didn't think of everything up front. Rather like an old system that's been patched to death and has to be tossed because it just can't keep up with changes. I think the fear exaggerated, particularly if the design-build team is at least roughly aware of the whole project dimensions.

The advantage of more-incremental projects that are never large because you take one part at a time is you develop in priority order. The 80/20 rule suggests that 80% of the clients will want about 20% of the options available - so get 20% of the offering working, and working well, first.

Clearly this is all because of {current President} and all the rest of the {President's affiliated party}. If only this were done by {opposing party to that of the President} instead none of this would have happpened!

I wrote a tasteful missive about the dangers of politicians of all creeds, stripes, colors. When it came time to click "submit" I just couldn't bring myself to do it. Modern politics is brought to us by the Seventh Circle of Hell. I laugh so that I do not cry.

The first steps of progress in making things better would be if one party gained some competence, and the other turned off their Petty Hate Machine(tm). You, humble reader, can decide which party is which. Choose the one that makes you happiest and upm

If only we had a congress full of people who often disagree but at least respect each other. That lack of respect is just turning our lawmaking process into an arrogant power struggle - "I'm right and you're just stupid."

I buy individual insurance for $165 a month. That is with a $500 deductible, and 0% coinsurance. My plan will be illegal on jan 1st, because it does not cover maternity care amongst other things. My plan is the equivalent of a platinum plan on the exchange. I just got quotes for a platinum plan with the same deductible, and quotes ranged from $420-$700 a month. Fuck you, and everyone else who thinks this law is a good thing. It just destroyed my ability to buy insurance. BTW, I am not even eligible t

Well, yes. This is the basic problem solved by mandatory health insurance (Obamacare) - you generally don't need expensive healthcare until you've lost your health, and thus can no longer pay for it. As you said, a very similar situation to SS, where the problem is that many don't save for retirement unless forced to. If you want you can think of it as a subsidy of the old by the young, but it's no less correct to think of either as a form of forced savings. (Not that "your" gold coins are sitting somewhere in a vault, because they aren't, but that doesn't really change anything).

The numbers you cite are very unusual, and only found among the youngest applicants and particularly what you would call the working poor, in some select states. Waiting lists to get insurance at $75 a month through state governments can have 18 month delays, or worse. My own native state of Tennessee tried to implement a system called Tenncare, which had prices in that range, but had to force many poorer applicants off the system and throttle it back, and they now have a situation where they announce once

So we don't need any taxes, then? Heck, we don't even need any government bonds for funding! Why half-measures, why not send $1M to everyone? I wonder how that would end: "since we adopted the leaf as the currency, we're all rich!". I can see no flaw in this plan.

No, wealth is unaffected by inflation. Wealth is not a stack of dollar bills. You must me invested in the means of production to have wealth, and the value of that is determined by what's produced, not the currency in use.

Hyper-inflation destroys savings, not wealth. Usually, hyper-inflation also destroys economies and governments. And, of course, it would be hyper inflation: with no practical limit on how much the government could spend, it would try to spend infinity dollars on pork barrel projects and outright checks mailed to supporters.

I doubt people would but precious metals, though, there are several stable national currencies, easier to just us Canadian dollars or Swiss francs or whatever, if it came to that.

The dirty secret is that in recent auctions, the Federal Reserve bought 90+% of those - nobody else wants them.

What the heck are you talking about? Even in the most recent auction, in the middle of the government shutdown, there were still bids for 2.75 times [marketwatch.com] the amount of debt the Treasury was actually offering in 1-month T-bills, which are the most volatile. For longer-term T-bills, the numbers are much better. In recent years, you often tend to see bids for at least 4 times the value of securities at auction.

Claiming that "nobody else wants them" is pure BS. There is no "dirty secret" here. The Fed often gets "first dibs" at auctions because of their role in managing the money supply, so they do buy up a lot of T-bills, but that doesn't mean there weren't lots of people waiting in line to buy that debt.

Admittedly, the numbers are down in terms of the numbers of bids in recent auctions (and we'd expect short-term bids to be down given the craziness in Washington), but your implication that the Fed is buying them up because no one else would is completely and utterly bogus.

The reason for the mandate (and for the original single-payer system) is that currently the cost of health care for the uninsured is hidden in the "uncollectable debt" category in the hospital's accounts receivable. It's all the bills for ER visits and emergency care for people who can't pay. I was taught a basic rule back in high school business classes: you can't manage costs until you've got them laid out where you can see them. The idea was to get all health care being paid for and accounted for so we can see where the money's going and do something about the areas where it's costing more than it should. It was also to help with shifting the costs from expensive emergency care to much cheaper preventative care, the idea being that when people know they're covered by insurance they're more likely to go to the doctor before things get critical instead of putting it off and hoping they get better so they don't get nailed with a doctor's bill and ending up at the ER in critical condition. If you have no insurance the bill's going to be a killer either way so it makes sense to go for the chance to avoid it, whereas if you do have insurance the bill won't kill you either way so why wait and suffer more than you have to?

There's a problem with that: the laws that say hospitals can't turn people away when they show up in the ER with a problem. And frankly there's very good reasons for those laws. We had a system where hospitals wouldn't treat you if you couldn't pay, and it resulted in major public-health problems that were costing the country (not the government, the country) huge amounts of money to deal with. So we changed the system.

NB: we had the same situation and the same problems when we had private fire departments. We changed that system for the same kind of reason: out-of-control fires caused by fire departments not responding because none of the houses they were getting paid to protect was on fire yet, and by the time they did respond half the block was burning and there was no way to control the blaze.

Here is the short description on why hospitals cannot turn away patients from the ER anymore like they used to.

In 1986 and 1987, 2 articles appeared in the literature by physicians from Cook County Hospital in Chicago detailing the extent of patient dumping to that facility (1, 2). The authors defined dumping as “the denial of or limitation in the provision of medical services to a patient for economic reasons and the referral of that patient elsewhere” (1). The majority of such transfers to Cook County Hospital involved patients who were minorities and unemployed. The reason given for the transfer by the sending institution was lack of insurance in 87% of the cases. Only 6% of the patients had given written informed consent for their transfer. Medical service patients who were transferred were twice as likely to die as those treated at the transferring hospital, and 24% of the patients were considered to have been transferred in an unstable condition. It was concluded that this practice was done primarily for financial reasons and that it delayed care and jeopardized the patient's health. This practice was not limited to Chicago but occurred in most large cities with public hospitals. In Dallas, such transfers increased from 70 per month in 1982 to more than 200 per month in 1983 (1).

So ~30 hostage-takers get to override the other 500 House and Senate members? We have a first-past-the-post system, which guarantees a 2-party system. If we had a proportional system, we could have these kind of splinter groups in a coalition government, much the way Israel runs. But when one faction holds its breath until it turns blue, the whole government can fall. We HAD a national referendum on Obamacare, i.e. the last presidential election, where the Republicans were the ones who wanted to make the election about it - AND THEY LOST.

Agree to delay the individual mandate, in exchange for a repeal of the debt-ceiling laws.
Give republicans what they want: they don't have to sign up for health care if they don't want to, and there will be no penalty.

Yes and I'm sure it will all end there. [/sarcasm] No, giving in to extortion only leads to more extortion. What Republicans want it to get something they could not get through the normal legislative process, so they're throwing this tantrum and holding their breath until they get what they want. As any parent knows, condoning this type of behavior only reinforces such behavior.

No one *has* to sign up for healthcare and the penalty in 2014 is $95 (ninety-five).

Hmm, they've been developing the software for the last two or three years, and the shutdown began the day the site went live, it's extremely unlikely that the one impacted the other.

Or are you suggesting that Obama decided to treat Healthcare.gov like the WW2 memorial, and deliberately sabotage it? Hint: making your biggest achievement as President look bad is NOT a way to build a legacy....

You really think the President is going around shutting down just vet memorials to make some kind of a point? A shutdown means government services are shut down. Just because a handful of congressmen stand outside of the most controversial ones, doesn't mean that's all that our government has stopped doing. Pretty clueless for people to start taking a strategy one wing of the Republican House has bragged about for MONTHS now and blame it on the President.

The memorials are open air lawns and monuments. The administration actually had to spend money to bring in fencing and armed guards to "shut them down". If the administration had wanted to, they could have simply put up a sign saying "Monuments closed. No security present. Use at your own risk." Then let American citizens and foreign visitors walk on the grass and take pictures of statues just like every other day.

You can make the argument that the shutdown is the sole fault of the Republicans. You are delu

These facilities always have security to prevent vandalism and stupid, irresponsible people doing stupid, irresponsible things on them. We're not going to risk our monuments especially at a time when there's a lot of hostility towards this shutdown. Google for what JUST happened to the Lincoln memorial getting spray painted.

These facilities always have security to prevent vandalism and stupid, irresponsible people doing stupid, irresponsible things on them. We're not going to risk our monuments especially at a time when there's a lot of hostility towards this shutdown.

Security of national monuments is a law enforcement function. The fact that the various government agencies have furloughed their law enforcement personnel means that law enforcement is not considered an essential function at any of those agencies. Think about it.

The local lighthouse is a BLM operation. The gates are closed and locked. There is plenty of parking outside the gates, and people can easily walk past the gates to access the lighthouse and the other facilities. Bikes could get past those gates

So the logical thing would have been to install those fences and station armed guards every evening after the memorial was vandalized. Not all day a couple months later to keep daily visitors out.

Keep defending it if you want, but the people of this country know when someone is acting like a spoiled child, taking his toys and pouting in the corner. This has nothing at all to do with the shutdown, and everything to do with an ego.

I think the fact that the Lincoln Memorial was just so easily defaced is contrary to your argument and I get the impression you've never visited D.C.. I've walked through the WWII memorial in the middle of the night with no guards or cameras around. President Obama has practically admitted to making the Govt Shutdown and Sequester hurt because he's for larger government. Shutting down the WWII memorial, and the Nordmandy beaches in France, and State/Federal co-sponsored monuments ARE political acts.

What hostile minority? It is the executive branch that was âoeexecutingâ the plan. Considering that this is seen as Obama's greatest achievement and Obama gets the pick the staff I can't think of a minority opposed.

If you are talking about the backseat drivers - the Republicans - well congress has oversight but no powers in this case. Sigh. No. This falls squarely on the shoulders of Obama.

Considering testing was slated to BEGIN the day before launch, I doubt it.

The contractors were too busy designing all of the "Due to the government shutdown, this website is closed" websites for all of the other government sites, so they didn't have enough time to work on the launch of the new site.

The contractors were too busy designing all of the "Due to the government shutdown, this website is closed" websites for all of the other government sites, so they didn't have enough time to work on the launch of the new site.

Hardly. More along the lines they hired a company with a poor reputation, that other governments had already experienced. See the "eHealth" scandal. [wikipedia.org]

"New York State's healthcare plans range from Fidelis Care's 'Bronze' plan at $810.84 per month to $2554.71 per month for something I didn't bother to look up because if I had $2500+ a month to spend on doctors, I'd buy a doctor and have him/her live with me and dole out pills like I was Michael Jackson. The deductibles - the amount you pay out of pocket every year before you the insurer has to give you anything at all - are outrageously high. Fidelis Care Bronze has a $3000/year deductible per person. I'm in pretty good health; it's a rare year I spend that much on doctors. After the $3000/year deductible, they pay 50% of your bills. So if you rack up $5000/year in medical bills, you pay $4000 and they pay $1000. Pretty damned crappy."

1) You had no catastrophes during your payments! Yay! Now, your neighbor and his wife and kids (who have the same insurance as you) got into a rollover car accident. They managed between them to accumulate $600,000 of healthcare bills. The insurance-hospital-doctor contracts reduced that down to $275,000. So, a chunk of your $46,620 went to pay that. (And yes, still left the family with a near-impossible bill to reduce in copays.)

But if it had been *you* and *your family* then you might be more glad that your neighbor was there paying that amount for a part of your coverage, too.

2) Now, the insurance companies do not just need to pay the (minimal cost necessary for) health care... if they did, they'd charge you a lot less. Instead, they have to make a profit each quarter. Every quarter. Year in, year out, they have to post ever-higher profits. Or their little worlds fall apart. So, where they would have paid $350,000 ten years ago, they paid out $275,000 today to the health care team that took care of that family.

The next time you hear a commercial health insurance company, take a moment to look at their financials - look them up on Google Finance, or maybe their investor-relations website. How often do insurers take hits on their profits?

Hint: While most physicians have been treading water the last ten years, trying to make do with dwindling reimbursements, the insurance companies profits climb steadily higher. (And yes, the insurance companies may pay out more aggregate dollars each year in care, but I guarantee it is not at the expense of their profits.)

I forgot to mention this above, but no insurance is just not an option. You will happily hoard your money and pretend you don't care, until you need help. Then you will be a charity case at the hospital, expecting society to take care of you.

You can say it ain't so, but it is so... Everybody needs to contribute, everybody needs to benefit.

to pay a minimum of 80% of premiums towards benefits. Excess is to refunded to the buyers.

Personally, I would rather have a Single Payer system (Medicare for All) but we weren't about to get that with the political influence the Health Insurance companies have. (And it would be disruptive to all the people employed by the Health Insurance companies).

And if you think that the Republicans aren't getting money from the Health Insurance companies, I have a bridge that I can sell you.

We'll we can always go back to the old system when you couldn't even buy health insurance because of some common pre-existing condition like hypertension. Or if you happened to have insurance and fell sick they would find some way of cancelling your insurance.

Or you missed a payment because they typed the wrong checking account number into their system over the phone and your payment failed because of THEM and then they considered it a missed

That was the fallback position to a fallback position. If they'd have done it right like the left wanted it, we'd all be on Medicare right now.

But that's socialism, so we can't have that. We need another kludgy hack to our current healthcare system which itself is a hack in the tax code to make it such that employers would want to pay for their employees' health care.

Not to worry. It is not like the customers of Healthcare.Gov are going to go shopping anywhere else. They have captured 100% of the market at the barrel of a gun. It is like the old American Telephone & Telegraph phone service, except they can go into your checking account for a billing dispute, or take your tax refund if you refuse to do business with them.

Sorry, you're just full of crap. Didn't you even read the summary of the summary about the bill? If you have insurance from *any* source, you don't need healthcare.gov. Even if you *don't* have healthcare now, you can still go to the state exchange... if you don't live in one of the Republican-run states that stamped their feet and refused to set up and exchange to help their own people.

That is really interesting, but what I actually meant was that my understanding was users could go to other websites to go shopping for health insurance - e.g. the websites of the insurance companies themselves - and purchase insurance directly without ever involving healthcare.gov

If my understanding was correct, then the claim by 'Austrian Anarchy' that "They have captured 100% of the market at the barrel of a gun." is false. My understanding may not be correct: I am not in the U.S.A., so I don't read as much about it as I would otherwise.

That is really interesting, but what I actually meant was that my understanding was users could go to other websites to go shopping for health insurance - e.g. the websites of the insurance companies themselves - and purchase insurance directly without ever involving healthcare.gov

If my understanding was correct, then the claim by 'Austrian Anarchy' that "They have captured 100% of the market at the barrel of a gun." is false. My understanding may not be correct: I am not in the U.S.A., so I don't read as much about it as I would otherwise.

Ah, I see. I suppose it's possible. When I was a contractor, I choose not to have health insurance, and paid cash for medical and dental as the need arose. (I was somewhat surprised to discover that doctors were willing to heavily discount their prices when they discovered I was paying cash.)

I see a couple of potential problems. The first is that any policy that provides better (past some level) coverage than government issue pays a 40% tax on the difference. This has served to dry up many private insu

I learned that most people fail to understand the importance of a good software architect.

The problem is worse than that. Most folks don't understand how hard and expensive good software is to develop and deploy.

Remember, most folks only see the stuff that works. Nobody remembers Yahoo, Google or Amazon when they where struggling to keep the servers alive. We barely hear about Netflix when they are down... This stuff just works and most don't have a clue the effort that goes into making that happen.

Obama's administration was in *WAY* over their heads trying to put the infrastructure in place for the marketplace. NOBODY tries to field a complicated website at full capacity on a single day, at least nobody who's actually been successful at this. You ALWAYS soft start and ramp up to production goals. The whole idea is as unworkable as the website implementation turned out to be. But that's politics. Make confident assertions about things you have no clue about.

But that's government for you. Doing STUPID things in a big and expensive way then throwing money at the problem to fix it.

...wasn't the whole "dot bomb" crash about doing stupid things (pets.com) in an expensive way (all those Aeron chairs) and throwing more money at the problem to fix it? The notion that "government" is a worse bureaucracy than other large bureaucracies like, oh, a healthcare insurer, say... has never clicked with me; I've tried to get service from (or worked in) too many large private bureaucracies.

Well, no. The Dot Bomb was caused by wild irrational exuberance. I have yet to meet a government bureaucracy that was characterized as having âoewild irrational exuberanceâ.

And I think there is an important difference. If a company has poor customer relations people will go elsewhere or start up their company. The old companies will go bankrupt. The amount of damage is limited.

Government bureaucracies are different. If they fail they don't go out of business. Often another layer of regulation and bureaucracy are laid on top of the old so the whole thing grows. (I also think it ties to incentives and who chooses to work for government. In business risk generally have huge upsides with limited downsides. In government that is reversed. Risk taking is meet with limited upsides and serious downsides.)